Child FIRST REFERRAL FORM

DATE OF REFERRAL: Date of receipt: / / CHILD INFORMATION: / / REQUEST FOR SERVICE Name (First / Last): DOB: / / Age: Child First Staff Initials: Gender: M F unknown Racial Origin: American Indian/Alaskan Native Asian Black/African-American (check one) Native Hawaiian/Other Pacific Islander White Other Hispanic Origin: Hispanic Non-Hispanic Client Insurance Husky A Husky B Private: Unknown None

CAREGIVER INFORMATION – Person(s) with whom child resides : 1st Caregiver Name: Age: Gender: Male Female Relation to child: biological parent adoptive parent foster parent relative:  other:

2nd Caregiver Name (optional): Age: Gender: Male Female Relation to child: biological parent adoptive parent foster parent relative other: Street address: Town/State/Zip: Phone: (check preferred #) Home : Mobile : Work : Best times to contact: 7-9am 9-12pm 12-5pm 6-9pm Email address: Is this the child’s legal guardian? Y N unknown If no, name of legal guardian: Legal guardian contact information: Days & Hours available for services: M T W Th F // 8 am – noon noon – 4 pm 4-7 pm Is English spoken fluently by caregiver/guardian? yes no unknown Primary language: Do you have caregiver’s permission to make referral? yes no If yes, written verbal both Has family previously been served by Child First? yes no unknown If yes, when? Does child/family have history of DCF involvement? none yes, present yes, past unknown If yes: CPS FAR unknown Name of FAR agency:

REFERRAL SOURCE INFORMATION Name: Relation to caregiver/guardian: Name of agency: Position: Street address: Town/State/Zip: Telephone: Office: Mobile: Fax: Best times to contact: 7-9am 9-12pm 12-5pm 6-9pm Email address: Type of Referral Source: Caregiver self-referral Relative Birth to Three Early Childhood Consultation Home visiting (Nurturing Family, Court personnel Partnership (ECCP) PAT, Dept of Children and Families (DCF) Early childhood EHS, NFP) DCF – Home-based service (IFP, FBR, education/childcare Hospital – Emergency Room (ER) IICAPS, FES-Triple P, Caregiver Emergency Mobile Psychiatric Hospital – Obstetrics Support Service Mental health provider - adult Team, other ) (EMPS) Mental health provider - child DCF – Care Coordination Faith based organization Regional Education Service Center Dept of Developmental Services Family resource & support (RESC) (DDS) center School System Dept of Social Services (DSS) Health Department (WIC, Shelter - family Dept Mental Health & Addiction Serv Healthy Start) Substance abuse program (DMHAS) Health provider – adult Other Domestic violence agency or shelter Health provider – pediatric Help Me Grow

REFERRAL INFORMATION Please describe the concerns that have led to this referral: Please also indicate if referral is urgent and why. If DCF referral, please indicate status and goals.

Reasons for Referral: (Check all that apply) Basic needs (e.g., housing, heat, Child abuse/neglect Parent/caregiver mental health food, TANF, SNAP, HUSKY) Risk of child out-of-home Parent/caregiver substance abuse Child developmental/educational placement Parent support and education concerns Risk of child expulsion from needs Child behavioral/emotional concerns school Service coordination needs Child exposure to violence Risk of family eviction Other (please specify) Major child/family health concerns

Other Services/Agencies Currently Involved with Child/Family: (Check and circle program if appropriate) Birth to Three Early Childhood Consultation Home visiting (Nurturing Family, Court personnel Partnership (ECCP) PAT, Dept of Children and Families (DCF) Early childhood EHS, NFP) DCF – Home-based service (IFP, FBR, education/childcare Hospital – Emergency Room (ER) IICAPS, FES-Triple P, Caregiver Emergency Mobile Psychiatric Hospital – Obstetrics Support Service Mental health provider - adult Team, other ) (EMPS) Mental health provider - child DCF – Care Coordination Faith based organization Regional Education Service Center Dept of Developmental Services Family resource & support (RESC) (DDS) center Shelter – family Dept of Social Services (DSS) Health Department (WIC, School System – Special Education Dept Mental Health & Addiction Serv Healthy Start) Substance abuse program (DMHAS) Health provider – adult Other______Domestic violence agency or shelter Health provider – pediatric Help Me Grow

I ______, legal guardian of ______, give permission for this referral to be sent to the Child First affiliate agency ______and for information to be sent to the Child First National Program Office. I understand that I will be contacted by the Child First affiliate agency directly to learn more about Child First and if it is an appropriate service for my child and my family.

Legal guardian signature: ______Date:______

Referrant signature: ______Dare:______

PLEASE RETURN TO: The Village Child First Program - email: [email protected] or Fax: (860) 231-8449 Contact the Village at (860) 236-4511 with questions.

PLEASE ATTACH THE CHILD FIRST CONSENT FOR SERVICES.